Consent

 
20% of survey complete.
Consent to securely transmit and store personal health information

This form collects and stores Personal Health Information.  All information is sent and stored in encrypted format.  Our technology vendor has signed a HIPPA Business Associate contract to ensure they comply with all HIPPA rules to protect your health information.

Please review our HIPPA Security Policy at Specialty Natural Medicine by clicking here for more information on how your personal health information is protected.

Specialty Natural Medicine requires all new patients to provide new patient information via this online form.  If you do not wish to use this form, please contact us immediately to cancel your new patient appointment.

Question Title

* 1. Do you consent to have your New Patient information securely transmitted and stored with Specialty Natural Medicine and our HIPPA compliant technology vendors?

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